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Fever in the Pediatric Patient

Fever in the Pediatric Patient. Mercedes Blackstone, MD Division of Emergency Medicine Children’s Hospital of Philadelphia. Objectives. Understand the basic physiology of fever Know the approach to common infections that present w/ fever in children

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Fever in the Pediatric Patient

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  1. Fever in the Pediatric Patient Mercedes Blackstone, MD Division of Emergency Medicine Children’s Hospital of Philadelphia

  2. Objectives • Understand the basic physiology of fever • Know the approach to common infections that present w/ fever in children • Learn the basic approach to management of children with fever based on their age

  3. What is fever? • Many definitions used, but typically temperature elevation ≥38°C (100.4°F) in infant, ≥ 38.5 (101.3°F) in older child • Core temperature measurement most accurate • Bladder thermistor (impractical, and painful) • Rectal most frequently used

  4. What is fever? • Fever is not a disease in itself, rather, it is a manifestation of a disease process • Fever primarily occurs for three reasons: • Host defense: prevent infecting organism from functioning properly • Increase in endogenous pyrogens (IL-1, IL-6) • Exogenous chemicals (drugs)

  5. What is fever?

  6. What is fever? • Core temperature regulation • Hypothalamus • Set point = 37°C (98.6°F) • Infections often alter set point to produce fever • Hypothalamic injury results in erratic control

  7. Hyperpyrexia vs. Hyperthermia • Hyperpyrexia is extreme elevation of body temp ≥ 41.5°C due to high set point • Hyperthermia results from uncontrolled temperature regulation (e.g. heat stroke), body temp rises above set point • Hyperpyrexia ≠ Hyperthermia !!

  8. Fever Treatment • Treatment of fever is NOT necessary • Elucidating and treating underlying etiology more important • Anti-pyretics (e.g. acetaminophen and ibuprofen) may make children more comfortable, but do not “cure” fever

  9. Fever in Pediatrics

  10. Common Febrile Infections • Viral • Upper respiratory (e.g. RSV, influenza) • Gastrointestinal (e.g. rotavirus) • Enteroviruses • Bacterial • Otitis media • Streptococcal pharyngitis • Pneumonia • UTI • Sinusitis

  11. Fever in Pediatrics • Concerns about fever in children • Higher association with severe infections • Parental anxiety (“fever phobia”) • Fever is a very non-specific sign of infection • Most cases are not life-threatening

  12. Fever in Pediatrics • Fever represents 20% of all pediatric ED visits • Youngest children at higher risk of severe infection • Impaired host defenses • Neutrophil chemotaxis/killing • Lymphocyte production • Complement function • Decreased pathogen clearance • Impaired ability to localize infection

  13. Fever in Pediatrics • Age useful in developing approach • 0-56 days = “The Febrile Infant” • 2-36 months = “The Febrile Young Child” • >3 years = Similar to adolescents and adults • Infections and management significantly differ by age!!

  14. Case #1 A 33 day-old infant male presents for a fever. Per mother, he has been slightly cranky, but there are no other symptoms present. His brother has a cold. On presentation to the ED, he is alert and vigorous. The temperature is 38.40C. The rest of the exam is normal.

  15. The Febrile Infant • Highest risk for life-threatening infections • Serious Bacterial Infections (SBI) • Bacteremia • Meningitis • Urinary tract infection • Bacterial enteritis • Skin and soft tissue infections • Bone and joint infections

  16. The Febrile Infant Common clinical manifestations of SBI • Fever • Irritability or lethargy • Poor feeding • Respiratory distress • Vomiting and/or diarrhea • None !

  17. The Febrile Infant • Most common infecting bacterial organisms • Escherechia coli • Group B streptoccus (GBS) • Listeria monocytogenes (<30 days) • HSV Type 1 and 2 may also produce severe infection below 21 days of age

  18. The Febrile Infant • Physical exam often very unreliable • Diagnostic testing indicated to exclude SBI • Majority admitted for observation and empiric antibiotic therapy

  19. The Febrile Infant • “Septic Work-up” • Complete blood count, blood culture • Urinalysis, urine culture • Lumbar puncture • Chest radiograph (if respiratory symptoms) • Stool cultures if symptoms

  20. The Febrile Infant • Several protocols developed • Rochester Criteria (Dagan, 1988) • Boston Protocol (Baskin, 1992) • Milwaukee Criteria (Bonadio,1993) • Philadelphia Criteria (Baker, 1993) • Goal is to identify febrile infants who can be discharged home safely

  21. Philadelphia CriteriaLow Risk Criteria • Infants age 29-56 days • Reliable caregiver and ability to follow up closely • Physical Exam: Well-appearing (YOS < 10) and without focus of infection • Laboratory criteria • WBC: 5-15,000 and I/T ratio: <0.2 • Urinalysis: <10 WBC/mm3 or hpf; GS(-) • CSF analysis: <8 WBC/hpf; GS(-) • CXR: No infiltrate Baker MD, Bell LM, Avner JR. New Engl J Med, 1993

  22. Philadelphia Criteria • Randomized Clinical Trial • If all “low risk criteria” were met: • Treatment group #1 • Inpatient observation • No empiric antibiotics • Treatment group #2 • Outpatient observation with follow-up • No empiric antibiotics • All “high-risk” were admitted to hospital

  23. Philadelphia Criteria • Results • 747 febrile infants (5 years) • Low-risk group • Inpatient (n=148): 1 SBI • Outpatient (n=139): 0 SBI • High-risk group (n=460): 64 SBI (13.9%) • Conclusions • Sensitivity=98%, NPV~100% • Outpatient therapy safe and cost-effective • Empiric antibiotics not necessary

  24. “Consensus” Low-Risk Criteria • Who: Age 29-56 days • History & social • Normal past history • Perinatal history • >37 wk gestation • No significant complications • Reliable caregiver • F/U in 24 hours • Physical Exam • Well-appearing • No focus of infection • Laboratory • WBC: 5-15,000 • I/T ratio: <0.2 • UA: <10 WBC/hpf • CSF: <8 WBC/mm3 • CXR: No infiltrate

  25. Approach to the Febrile Infant Age 0-56 days Fever 380C • Septic Work-up • CBC w/diff, BCx • Cath UA, UCx • CSF studies • CXR (if URI Sx) 0-28 days 29-56 days • Admission • Immediate antibiotics • Acyclovir < 21 days

  26. Low-Risk • PMHx normal • Well-appearing • Labs normal • High-Risk • PMHx abnormal • Ill-appearing • Abnormal labs • Admission • Immediate antibiotics Approach to the Febrile Infant 29-56 days • Option #1 • Outpatient mgmt • 24-hour follow-up • Withhold antibiotics • Option #2 • Inpatient observation • Withhold antibiotics

  27. Case #2 An 11 month female presents to your ED for fever of 2 days duration. She has no other symptoms. Physical exam reveals a well-appearing, interactive infant. The temperature is 40.20C, but the remainder of her exam is normal.

  28. Febrile Young Child • Physical exam more reliable and immune systems mature • Can exclude most SBI by history and physical examination alone • Two infections may still be “occult” in this age group

  29. Febrile Young Child • “Fever Without Source” • Temperature  39.00C • Normal physical exam • Well-appearing • No obvious bacterial illness • No petechiae • NOT same as Fever of Unknown Origin (FUO)!

  30. Febrile Young Child • Occult Bacteremia • Pathogenic bacteria present in blood • Haemphilous influenzae type b • Streptococcus pneumoniae • Potential to lead to invasive infection • Occult Urinary Tract Infection (UTI) • E. coli and other gram-negative enterics • Enterococcus

  31. Fever and Occult Bacteremia

  32. Occult Bacteremia • Increased incidence • Age: < 36 months • Fever:  39.00C • Management • Consider WBC count, ANC, blood culture • Consider Empiric antibiotic therapy • Temporal changes in bacterial prevalence

  33. Occult Bacteremia • Pre-1990: Pre-Hib vaccine era • Incidence: 2.8% to 11.1% • SBI from Hib occult bacteremia 25-44% • Outcomes improved with empiric antibiotics and follow-up

  34. Post-vaccination IncidenceHaemophilus Influenzae type b Data from Centers for Disease Control, MMWR, 1995

  35. Occult Bacteremia • Studies post-Hib Vaccination • OB rate approximately 1.5-2% • Predominantly S. pneumoniae • Contamination rate ≥3.0% • Development of severe infections from pneumococcal bacteremia very rare

  36. So where are we going now that we have Prevnar®???

  37. Post-vaccination IncidenceStreptococcus pneumoniae Black S, Shinefeld S, Pediatr Inf Dis, 2003

  38. Current Approach to Occult Bacteremia • Occult Bacteremia in febrile young children • Prevalence likely <0.5% and decreasing • One dose of PCV7 is 88% effective • Management • CBC and blood culture?? • High false-positive rate (contaminants) • Will need repeat culture • Over-treatment • Empiric antibiotics?? • Most will spontaneously resolve • Not efficacious in preventing SBI

  39. Occult UTI • Symptoms of UTI limited < 3 years of age • Fever is often lone presenting sign of UTI • “Occult” UTI can occur even with source such as otitis, URI, or gastroenteritis • Prevalence of Occult UTI: 3.3-5.3%

  40. Occult UTI • Risk factors • Caucasian > Latino > AA • Age ≤ 12 months • Fever ≥ 39.00C • Duration of fever ≥ 2 days • No source of fever • ≥ 3 risk factors: Sensitivity = 88%* • Uncircumcised males: 10-fold risk increase *Gorelick et al, 2003

  41. Occult UTI • Catheterized or suprapubic urine ONLY!!! • Positive UA • Urine Dipstick: (+) nitrite and/or Mod LE • Low FPR (specificity) allows for empiric treatment • Rapid, cheap, and effective! • Microscopic UA: > 10 WBC/hpf • Always send urine culture • Gram (-) enterics: Cefixime, TMP-Sx, cephalexin

  42. Well-appearing Ill-appearing, Non-toxic Toxic-appearing • <12 months • Cath urine dip and UCx • Treat if urine (+) • >12 months • T/C urine, based on risk factors • Arrange follow-up • CBC w/diff and BCx • Urine dip and UCx • If WBC >15000 • T/C antibiotics • T/C hospitalization • Treat if urine (+) • Septic Work-up • Immediate • antibiotics • Admission Approach to Febrile Young Child Age 2-36 mos Fever 390C

  43. Case #3 • A 9 year old female presents to your ED for fever and sore throat for 3 days. She has vomited several times, but does not have diahrrea. There are no upper respiratory symptoms, dyspnea, or dysuria. On exam her T=40°C, and she is well-appearing. Here exam is only significant for an exudative, erythematous pharynx and anterior cervical adenopathy.

  44. Fever > 3 years of age • Ovewhelming cases are viral and do not require testing and/or treatment • Use clinical symptoms to guide testing, can localize symptoms • Pharyngitis  Rapid Strep test and/or culture • Dysuria  Urinalysis and culture • Tachypnea and crackles  CXR

  45. Summary • Febrile Infants • Complete sepsis work-up < 56 days • Consider outpatient management if low-risk and > 28 days • Reliable caregiver and follow-up essential • Febrile Young Children • Occult bacteremia is on the rapid decline • Testing and treatment for OB rarely indicated • Consider screening for occult UTI

  46. Summary • Older children with fever • Most do not need testing • Guide testing and treatment based on clinical symptoms • Treatment of fever is not necessary, but may make the patient more comfortable

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